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Orthopedic Emergencies Rachel Steinhart CCRMC ED April 2010 Objectives Review H&P for orthopedic emergencies Review appropriate documentation Describe x-rays Recognize potential limb/function threatening conditions Discuss some high-risk & some common injuries Review management including emergent/urgent orthopedic consult History Mechanism Past medical history Medications Dominant hand Occupation Previous injuries Last meal Physical Exam Inspect (deformity, swelling, skin) Palpate (step-off, tenderness) Range of motion (active & passive) Neurovascular exam Physical Exam Documentation Joint above - Joint below Sensory Motor Vascular Skin Compartments Neurovascular Compromise Straight forward Any sensory or motor deficit Any question of circulatory compromise Pallor or cold distal to injury Decreased capillary refill/pulse Compartment Syndrome Raised pressure in a closed fascial space Reduced capillary perfusion below level needed for tissue viability Limb Compartment Syndrome Causes Orthopedic Fractures: open or closed Fx management (e.g. tight casting) Vascular/Iatrogenic Vascular puncture: esp. anticoagulated Intra-arterial drug administration Extravasation of IV fluids Soft-tissue injury Crush (e.g. Police K9 bites) Burns Hypotension: Always worsens perfusion in compartment sx Each limb contains a number of compartments at risk for CS. Upper arm: anterior(bicepsbrachialis) and posterior(triceps). Forearm: volar(flexors) and dorsal(extensors) 3 gluteal, 2 thigh, 4 in the lower leg. Compartment Syndrome Risk Factors Tibial Fracture Incidence ranges 1.5 to 29% Variable dx/tx thresholds Anterior compartment most common Forearm Supracondylar Fracture Comminuted = increased risk Open = decreased risk (~50%) Compartment Syndrome - Pressure Threshold Intracompartmental pressure: Pressure as low as 30 mm H2O can result in compartment syndrome when accompanied by periods of hypotension Is it Compartment Syndrome? Clinical – 6 P’s Pain out of proportion - passive extension INCREASING NARCOTIC REQUIREMENT Paralysis Paraesthesia Pulselessness Pallor Poikilothermia - Cold Irreversible damage occurs 6 hours after ischemia begins Monitor Extremity Pulses Be sure to occlude the other major artery (e.g. posterior tibial artery vs. dorsalis pedis) so that retrograde flow does not interfere with diagnosis alternatively, apply a pulse oximetry monitor to the great toe, and sequentially occlude the posterior tibial and dorsalis pedis pulses compare pulses to the opposite, noninjured limb Measuring Compartment Pressure Usually performed by Orthopedist Is within Emergency scope of practice At CCRMC, Stryker instrument is in Med Room - Sterile kit w/needle and syringe must be obtained by Nurse Supervisor Describing Radiographs Type of fracture Transverse, oblique, spiral, segmental, comminuted Pediatric: Salter-Harris, torus/buckle, greenstick Location of fracture Displacement Shortening, angulation, rotation Associated dislocation Fracture Description Open Fracture Carefully examine skin If skin not intact, determine whether bone exposed Irrigate thoroughly - will require OR wash Bandage IV antibiotics (Ancef or Ancef+Gent) Tetanus Contact Ortho as soon as discovered QuickTime™ and a decompressor are needed to see this picture. Pediatric Fractures Fractures involving or near the epiphyseal plate require urgent orthopedic consult Salter-Harris Classification QuickTime™ and a decompressor are needed to see this picture. Joint Dislocation Complete separation of 2 articulating bony surfaces, often caused by a sudden impact to the joint Commonly dislocated joints include shoulder, finger, patella and elbow Dislocations are often associated with fractures Shoulder Dislocation Vast majority are anterior Document axillary nerve fxn preand post-reduction Sensation over deltoid Posterior associated with seizure activity, can be bilateral, often missed Anterior Posterior Peri-lunate & Lunate Dislocations Peri-lunate Lunate Both with significant wrist instability Both associated with SCAPHOID fractures Usually require surgical intervention Scapho-lunate Dissociation “Terry Thomas Sign” Gap normally 1-2 mm Unstable ligamentous injury Generally requires surgical repair Scaphoid Fracture Can be difficult to see on xray May require additional view May require delayed imaging If middle or proximal, risk osteonecrosis Contact ortho while patient in ER When in doubt, splint & refer Short arm, thumb spica Hip Dislocation Rapid reduction imperative: prolonged dislocation avascular necrosis Hip Fracture Potential For Avascular Necrosis > Knee Dislocation Anterior Posterior Arteriogram Usually reduce spontaneously Often associated with tibial plateau fx Posterior highly associated with vascular injury - vascular study IMPERATIVE Patellar Fracture Transverse fracture -> inability to extend leg at the knee Usually requires ORIF Maisonneuve Fracture Unstable fracture Often requires surgical repair Ankle Dislocation Easily reduced Associated with malleolar fractures and significant instability Usually require surgical intervention Lisfranc Fracture Unstable fracture Often requires surgical repair Jones Fracture Unstable fracture Often requires surgical repair Nursemaid’s Elbow Common Easily reduced Supracondylar Fracture Common pediatric fracture Significant risk for compartment syndrome Volkmann’s Contracture Unreliable parents? ADMIT for observation Often require surgical intervention Initial Treatment of Orthopedic Injuries Remove jewelry Ice Elevate Control pain Irrigate, dress, reduce, splint, dT, IV antibiotic NPO Dislocation +/Fracture Increase time dislocated = more difficult to reduce Reduction results in: Relief of acute pain Removal of pressure from neurovascular structures Restoration of circulation Splint immediately post-reduction to avoid recurrent dislocation Repeat physical exam and x-ray to confirm reduction & r/o addt’l injury Early Orthopedic Consult Emergent or Urgent Neurovascular compromise Attribute to initial injury or Post reduction Possible compartment sx Irreducible dislocation Fracture + dislocation Open fracture Risk of avascular necrosis (e.g. scaphoid, femoral neck)
